What is a ZPIC Audit?

Businesses that provide services covered by Medicare can occasionally find themselves under investigation by Zone Program Integrity Contractors, also known as ZPICs. ZPIC audits are intended to check for and reduce the occurrence of Medicare fraud.

The Audit

Medicare payments are monitored, and any unusual activity can be cause for an audit. During the investigation, ZPICs work to determine whether there is fraudulent activity, or if there are simply errors made in the billing process.

In cases where fraud is found, the case is sent to the Office of the Inspector General (OIG) and the Department of Justice (DOJ). While recuperation of overpayment is likely for those who simply had errors in their billing practices, fraudulent activity can result in monetary penalties and even criminal charges.

Common Mistakes During a ZPIC Audit

During an audit, ZPICs will require access to most or all business records. While it is good to cooperate with this process, employees sometimes certify that their information and documents are complete without checking, which can be a costly mistake for the facility and the professionals who work there.

Not having a qualified defense attorney with experience in Medicare fraud cases on your side to help you throughout the process can make it even more difficult. The audit process adds additional stress to the normal operation of a business, and can be confusing and overwhelming to everyone involved. In the end, it can become the perfect recipe resulting in errors that lead to negative results for the business, its employees, and even its customers — even if you didn’t advertently do anything wrong.

The Basics of an Appeal

If your ZPIC audit does end up with negative results, you do have the opportunity to appeal. However, many people are unaware of the appeals process for ZPIC audits, which can be even more complicated than the audit itself. First, there are five levels of appeal. The first two levels allow you to request a redetermination from the auditor, and to seek a second opinion from an independent contractor. After that, the appeal must be presented before a judge, appeals board, and finally a federal district court.

The audit and subsequent appeals progress can be long and drawn-out, and difficult to manage without recourse to a legal professional.

Although intended to protect consumers and businesses alike, ZPIC audits are a significant source of stress on a business and its employees. Good business practices, accurate bookkeeping, and experienced legal counsel are all key to getting through an audit, and any appeals that may result.

Speak with an Experienced Attorney About Your ZPIC Audit

As you can probably guess, the best thing you can do is ensure that you have a qualified legal team on your side. Make sure you don’t make costly mistakes that can affect your business and its employees. To learn more about defending yourself against a ZPIC audit or if you need assistance filing a ZPIC appeal, you can contact the attorneys at Oberheiden, P.C. For a free and confidential consultation, call (888) 727-5159 or complete our online contact form today.